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<meta name="description" content="听网课，疫情以来，我就没出去听过课了，都是听网课。看来以后是个趋势了。讲的老师比较多，我又在上班，就不明确注明哪位老师以及题目了，听到哪里就记哪里吧。第一场是拔牙技术专场。埋伏阻生牙拔除，我都是转诊的，pass。上颌窦侧壁开窗拔智齿的病例，高难度啊，pass。使用超声骨刀的原因：弯刀头，可绕过障碍物；路径长，可避免损伤软组织；刀头窄，定位准确；切割力小，操纵性强。微创拔牙的技术特点身体微创和心理微">
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        <p><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/01.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/02.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/03.png"><br>听网课，疫情以来，我就没出去听过课了，都是听网课。看来以后是个趋势了。<br>讲的老师比较多，我又在上班，就不明确注明哪位老师以及题目了，听到哪里就记哪里吧。<br>第一场是拔牙技术专场。<br>埋伏阻生牙拔除，我都是转诊的，pass。<br>上颌窦侧壁开窗拔智齿的病例，高难度啊，pass。<br>使用超声骨刀的原因：弯刀头，可绕过障碍物；路径长，可避免损伤软组织；刀头窄，定位准确；切割力小，操纵性强。<br>微创拔牙的技术特点<br>身体微创和心理微创同等重要。<br>基本技术：<br>①沟槽状去骨。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/04.png"><br>②八字旋转法。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/05.png"><br>分冠分根同时进行<br>③三段式分冠<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/06.png"><br>④多根变单根<br>⑤远中切口确定，近中袋形切口。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/07.png"><br>⑥扬角手机<br>⑦牙体着力点的制备。<br>阻力分析<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/08.png"><br>干嘛只限制10分钟啊，唉。<br>下八拔除难度分析<br>通过术前周全分析，确定详细治疗计划，提高医生技术，减少术后并发症，提高患者满意度。<br>阻力分析：冠部、根部、邻牙阻力。<br>文献：周宏志,胡开进,秦瑞锋等，下颌阻生第三磨牙拔除难度预判.口腔医学研究.2009年6月第25卷第3期:327-329.<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/09.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/10.png"><br>在各个相邻难度级别之间并非存在刚性的界限值，每位医生在临床操作过程中可能受到多种因素影响，无法象机械装置般规律准确。<br>看文章就行了。通过评分来判断难度。<br>拔牙是治疗的开始而不是结束。<br>“八”字扭转拔牙法<br>下颌垂直阻生的第三磨牙，可以用牙钳来拔。<br>不用牙挺的原因，邻牙是固定桥。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/11.png"><br>助手帮忙扶着患者下颌。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/12.png"><br>避免TMJ损伤。<br>医生用八字扭转法拔牙，是汉字的八，颊侧扭扭，停上几秒，舌侧扭扭，角度5度，即角度非常小。牙根一般是向远中弯曲的，脱位时钳子上抬，让患牙顺势脱出。</p>
<p>是扭，不是摇。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/13.png"><br>原理<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/14.png"><br>传统认为，用挺多是用摇动力，扭转只能用于圆根。5度的扭转更不容易断根。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/15.png"><br>扭转时牙周膜更容易断。<br>如果扭不出来，要想想是否有其它阻力存在。一两分钟扭不下来，快换其它方法。不要企图增大力量来拔除。其它牙位也可以尝试使用。<br>观众提问：<br>3D导板用CBCT还是螺旋CT？<br>CBCT辐射小，但分辨率不如螺旋CT。拍片时注意分离软组织和骨组织。<br>拔牙前影像学？<br>两种极端：不拍片或上来就CBCT。每位患者都需要术前影像学资料，避雷。单颗牙最好根尖片。最清晰，按标准拍不易失真。<br>后面来患者了，没记了一部分。</p>
<p>接下来是特殊人群拔牙的。<br>多生牙患者的临床影像特征分析。pass。<br>妊娠期拔牙的临床探讨<br>2013年美国妇产科协会：孕妇口腔疾患要尽早处置，包括X线检查。<br>尚无证据支持口腔治疗会增加流产概率。<br>老师自己的病例统计，118例孕妇拔牙，均安全分娩，胎儿一切正常。<br>尽快控制疼痛和感染。<br>心脏瓣膜置换术后患者拔牙的处理流程<br>提倡用超声骨刀或电动马达去骨。<br>时机：最好换瓣前。<br>处理方法<br>①改变抗凝治疗强度。有血栓风险。<br>②拔牙前用肝素代替华法林。需住院。<br>③不改变抗凝治疗，局部止血措施。出血较重。<br>相关指标<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/16.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/17.png"><br>措施<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/18.png"><br>抗凝处理<br>停药时间一般不超过4天。根据药物确定。<br>术后第一天使用抗凝剂。<br>尽可能与原手术医生联系。<br>必要时可皮下注射维生素K。<br>拔牙创处理<br>大部分常规压迫止血<br>渗血较多水平褥式缝合。<br>明胶海绵、碘仿加压。<br>抗生素应用<br>术后有菌血症，需术前应用。<br>严格掌握拔牙时机<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/19.png"><br>血压低了也不能拔。<br>局麻药<br>原理，阻滞钠离子通道，抑制去极化。<br>局麻药有舒血管作用，所以加肾上腺素。使用二磷酸盐类药物的患者不能用肾上腺素。最安全的局麻药物，斯康杜尼，但4岁以下不能用。其次是利多卡因。剂量为2%，但婴幼儿药典建议0.5%。有法律纠纷。孕妇用利多卡因是安全的。哺乳期用阿替卡因建议当天不哺乳。</p>
<p>11月29日下午<br>牙移植专场，这个就是听听而已了。<br>自体牙移植修复牙齿缺失<br>是活动、固定、种植以外的牙列缺损修复方式。<br>传统移植：用埋伏、阻生、萌出的牙齿来修复缺失牙。<br>牙槽窝预备时间长：3D打印导板。<br>骨缺失：骨移植。<br>意向性再植<br>要拔的牙，拔除后处理牙根面和牙槽窝，再将其植入牙槽窝。<br>要看患牙条件，患者保牙意愿。<br>牙移植中数字化技术有很多应用。<br>提问及小结：<br>再植的拔牙窝不要搔刮，移植牙尽量选同颌同侧，单根或锥形根的。术后固定选用弹性固定，时间不超过一个半月，时间太长会影响移植牙的咬合调整。术后复查牙髓活力，坏死则行根管治疗。牙槽窝预备宁大勿小，关键是保存牙根上牙周膜细胞的活力。</p>
<p>最后是即刻种植的内容，更是看看而已了。<br>即刻种植与延期种植在成功率上没有统计学差异。</p>
<p>11月30日上午 神经问题<br>下牙槽神经管问题<br>开头没听到<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/20.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/21.png"><br>拔下8时舌侧骨板骨折及舌神经损伤的问题。<br>损伤原因：直接损伤（麻药，骨折等），间接损伤。<br>近中及水平阻生的患牙的舌侧骨板较薄甚至穿孔，风险较大。<br>避免骨折及损伤的要点<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/22.png"><br>牙种植与下牙槽N损伤的规避<br>下颌管中血管在神经之上，种植时出血较多立即停止手术。<br>中国人下颌管在下颌骨内位置变异较大。<br>一些经验<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/23.png"><br>即刻种植<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/24.png"><br>颏孔处的问题<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0229-ycwk/25.png"><br>讨论：<br>神经损伤，治疗越早越好。一般是由于压迫、水肿造成的间接性损伤。</p>
<p>另一个专题<br>臭氧水冲洗拔牙创。<br>依托考普镇痛。<br>口腔颌面部疼痛。<br>有患者来了，听听就行了。<br>讨论:牙椅水路污染的问题。拔牙前疼不疼？疼的话要诊断清楚。尤其邻牙牙髓炎，要先开髓。疼痛的原因之一，炎性因子刺激神经末梢。应该保护创面，也可以用药，术前30分钟或术后即可。小剂量。尽量用安全的药物。洛索洛芬胶囊。临床实验要注意伦理学程序。</p>
<p>11月30日下午<br>出血专题<br>抗凝抗血小板治疗患者拔牙<br>拔牙时INR&lt;4.0。<br>全身局部因素：肾功能不全，毗邻肿瘤，年龄大…<br>尽量选择浸润麻醉。<br>控制炎症。<br>避开凝血药物峰值。<br>一次拔牙不超过3颗。<br>DSA（数字化减影血管造影）对拔牙后出血的诊断和介入治疗。<br>高原拔牙<br>缺氧，微循环障碍，红细胞增多致凝血机制紊乱，组织损伤修复缓慢继发细菌感染。<br>拔牙出血的原因及防治（胡开进）<br>出血原因：全身因素（后果严重）、局部因素（常见）。<br>全身因素：高血压、糖尿病、长期服用抗凝药、药物的交叉作用。<br>局部因素：误伤血管、血管畸形（血管畸形所累及的牙齿，是绝对的拔牙禁忌）、软组织损伤、牙槽骨损伤、牙槽窝残留肉芽组织、局部炎症。<br>术中出血的表现：活动性出血多见。<br>术后出血表现：血凝块多见。<br>建议拔牙后给患者留联系方式。拔牙出血严重的到院要叮嘱有人陪同。<br>诊断：①安抚患者；②卧位或半卧位；③拔牙出血局部检查。<br>多见有高出牙槽窝的过多血凝块等。<br>预防：被忽略的区域（磨牙后管等）。按最坏的情况做准备。无痛注射麻醉，减少不良刺激。<br>使用局部止血剂：明胶海绵、塞治剂等。<br>拔牙出血不可怕，可怕的是不知道怎么处理。</p>
<p>其它主题<br>双磷酸盐药物导致拔牙后化学性骨坏死：用于预防肿瘤骨转移。预防，询问病史，术前停药3-6个月。<br>上颌窦穿通处理：<br>小于3mm，直接缝合。<br>3-6mm，填塞缝合。<br>6-10mm，旋转瓣缝合。<br>大于10mm，翻瓣植骨。<br>明胶海绵等可吸收材料主要用于3-10mm大小的穿孔。<br>药物相关性颌骨坏死与口腔诊疗<br>坏死颌骨裸露或瘘管在口腔环境中8周以上，有服用相关药物史，无颌面部放疗史，且病变未非转移性肿瘤。<br>药物种类：抗骨吸收药物（双磷酸盐，抗骨质疏松，每年静脉用药一次，容易忘记。）、抗血管生成药物（抗肿瘤）、其它（化疗、肾透析、甲减、糖尿病……）<br>全科医生碰到建议及时转诊。</p>
<p>我觉得系统学习主要不是靠听课，听课主要是知道有这么回事，真正碰到了不会一脸茫然。真碰到了再去看书系统学吧。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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